Misuse of Steroids, Other Performance Enhancers Slips Under Radar

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DSM-5-TR recognizes 10 broad types of substance use disorders, ranging from disorders involving substances that can be purchased over the counter (alcohol and tobacco) to prescription medications (stimulants, hypnotics, and pain relievers) and illicit drugs (cocaine). However, some mental health professionals think one important class of substances remains missing from this list: anabolic steroids and other performance-enhancing drugs (PEDs).

Now, anabolic steroids are briefly mentioned in DSM-5-TR as an example that might fit in the “Other or Unknown Substance-Related Disorders” category. Harrison Pope, M.D., M.P.H., a professor of psychiatry at Harvard Medical School and leading researcher on anabolic steroids, is among those who think steroids and other PEDs deserve more clinical visibility. He noted that steroid users in particular show all the signs of biological and psychological dependence: they take larger quantities over time, experience withdrawal effects when not taking them, and continue to use them despite warnings to stop from loved ones or the emergence of adverse side effects.

PED use is also prevalent enough to deserve its own category, Pope said. A study published in 2020 found that about 16% of young men aged 18 to 26 in the United States reported using legal performance enhancers, such as creatine supplements, while nearly 3% reported using anabolic steroids (which are illegal without a prescription). Among women, 1.2% reported using legal PEDs, while 0.8% reported using anabolic steroids. Some of Pope’s own research has indicated that there may be as many as 1 million adults in the United States who show the signs of steroid dependence.

“PEDs are definitely misused by many people and pose serious health consequences,” said Wilson Compton, M.D., M.P.H., deputy director of the National Institute on Drug Abuse and a member of the Substance Use Disorder (SUD) Work Group for DSM-5. “The question is do they share the specific criteria outlined for other SUDs?”

Compton told Psychiatric News that one of the key elements separating PEDs from other drugs in the SUD category is that steroids and other PEDs are not consumed for an immediate high but rather taken over weeks to gradually change body shape. Another issue is that some substances known to enhance performance, such as caffeine or amphetamines, are in existing categories.

What Drives PED Use?

With more data, PED misuse may one day fit into the chapter on eating disorders in the DSM.

Similar to people with an eating disorder, most people who use PEDs struggle with issues related to a distorted body image, said Kyle Ganson, Ph.D., a clinical social worker and assistant professor at the Factor-Inwentash Faculty of Social Work at the University of Toronto. (To the contrary of media narratives, PED misuse is not confined to bodybuilders, baseball players, or other high-performance athletes). PED misuse also often begins in adolescence, he continued; youth may see themselves as weak or flabby and undertake a range of behaviors including diets, increased exercise, and the use of substances to boost metabolism or muscle growth.

“These aren’t stereotypical eating disorder behaviors,” said Jason Nagata, M.D., M.Sc., an assistant professor of pediatrics at the University of California, San Francisco. “Instead of vomiting, they work out intensely; instead of diet pills, they overuse steroids.”

Because PEDs are more frequently used by males than females and the use of these products typically leads to a more toned body, PED misuse can be easily missed by parents, teachers, and even doctors.

“Typically, the person will start with one legal supplement like whey protein, then advance to a polysubstance pattern,” Ganson said. “For many, the trajectory may lead to illicit substances like steroids.”

A study of national survey data conducted by Nagata, Ganson, and colleagues found that male youth who use legal PEDs are about three times as likely to subsequently use anabolic steroids as those who do not use PEDs.

Even users who don’t progress to illegal PEDs face risks, Nagata said. Recent longitudinal data have also suggested that youth who use legal PEDs are more likely to subsequently engage in drinking, risky sexual behaviors, and criminal offenses compared with those who do not. Over-the-counter performance enhancers are also not harmless; as with many nutritional supplements, they are poorly regulated and often contaminated with other substances. (Nagata noted that a handful of states, including Massachusetts, have proposed regulations to ban the sale of muscle-enhancing and/or weight loss supplements to minors due to concerns over health risks.)

Screening for PED Misuse

As with Pope and others who have witnessed the detrimental effects of these drugs, Ganson and Nagata believe the misuse of steroids and other PEDs warrants its own section in the DSM. “It would help professionals better screen for this disorder in youth while also raising awareness about the male eating disorder experience,” Nagata said.

Nagata acknowledged the difficulty in finding a diagnostic home for PED misuse given how trans-diagnostic it is; in addition to sharing traits with substance use disorders and eating disorders, PED misuse overlaps with body dysmorphic disorder. Many youth who use these substances can develop unhealthy obsessions and repetitive behaviors related to their appearance. Nagata noted that muscle dysphoria, a disorder in which people become preoccupied with large muscles, was added to DSM-5 as a subtype of body dysmorphic disorder; however, that disorder reflects only a small portion of people who misuse PEDs.

Despite the lack of clear diagnostic criteria, there are clues psychiatrists and other health professionals can look for to identify potential cases of performance-enhancing drug misuse. As noted, this is primarily—but not entirely—an issue among young men, especially those who experience adverse life events or social stigma.

“It makes sense that youth who are put in positions to feel defenseless would turn to behaviors aimed at getting stronger,” Ganson said. He was part of a study published last year that identified childhood sexual abuse as a significant risk factor for both legal and illicit performance-enhancing drug use. “What was unusual in that study was that while women are much less likely overall to use PEDs, the rates of use among men or women who were abused were roughly similar,” he said.

Nagata added that PED use is also elevated among sexual minorities; a recent study he conducted found that around 44% of gay or bisexual men and 30% of gay or bisexual women had used PEDs in their lifetime; those that reported PED use were more likely to have symptoms of disordered eating or muscle dysphoria. Nagata said this elevated use is driven by both stigma and social media representations of ideal body types. Few studies have examined PED use in transgender individuals, but Nagata said that he believes some people transitioning from female to male would look for ways to become more muscular and masculine, so they might be another group likely to misuse PEDs.

Physicians should be prepared to ask patients who report mood swings and/or aggression about use of PEDs and other muscle enhancing behaviors.

“One of the issues complicating PED misuse is that we don’t know what crosses the line between the safe versus risky use of legal PEDs,” Nagata said. “Therefore, it is useful to focus on overall behaviors. Have the youth stopped engaging with friends or family to work out instead? Have they eliminated certain foods or made other major dietary changes? As with other substance use disorders, any use that has an adverse impact on their school, work, or social life is problematic.”

Pope noted that while patients who misuse steroids may be less willing to admit their use than those who use over-the-counter products, a routine blood test can provide clues whether a patient is misusing these substances. “Significantly lower levels of the good cholesterol (HDL), coupled with elevated bad cholesterol (LDL), is one telltale clue of steroid misuse,” he said. “Elevated numbers of red blood cells is another possible sign.” Other common symptoms of steroid use that might be seen by a primary care doctor include high blood pressure, truncal acne (on the back, chest, neck, or arms), and the emergence of breast tissue in men. “It’s important that more health professionals begin asking questions about these substances,” Ganson said. While many youth may be driven to start taking PEDs to become stronger, misuse can pose physical and mental health risks. ■